Endoluminal stapler with rotating wheel cam for multi-staple firing

ABSTRACT

A surgical stapler has a body, a shaft assembly extending distally from the body, and an end effector coupled with a distal end of the shaft assembly. The end effector has a stapling head assembly, an anvil, and a vacuum port. The vacuum port is operable to draw tissue between the stapling head assembly and the anvil. The anvil is operable to move toward and away from the stapling head assembly to thereby capture the tissue drawn between the stapling head assembly and the anvil. The stapling head assembly comprises a plurality of wheel assemblies and staple cartridges. At least one wheel assembly is operable to rotate to thereby move the anvil toward and away from the body. The remaining wheel assemblies are operable to rotate to thereby drive staples through the captured tissue. The body includes user input features operable to drive the wheel assemblies.

This application is a Continuation of prior U.S. application Ser. No.13/968,040 entitled “Endoluminal Stapler With Rotating Wheel Cam ForMulti-Staple Firing,” filed Aug. 15, 2013, now U.S. Pat. No. 9,597,074,issued Mar. 21, 2017.

BACKGROUND

Metabolic disease may result in various conditions including obesity,hypertension, diabetes, coronary artery disease, stroke, congestiveheart failure, multiple orthopedic problems, pulmonary insufficiency,sleep apnea, infertility, and markedly decreased life expectancy.Additionally, the complications or co-morbidities associated withmetabolic disease may affect an individual's quality of life.Accordingly, the monetary, physical, and psychological costs associatedwith metabolic disease may be substantial in some cases.

A variety of bariatric surgical procedures have been developed to treatcomplications of metabolic disease, such as obesity. One such procedureis the Roux-en-Y gastric bypass (RYGB). In a RYGB procedure, a smallstomach pouch is separated from the remainder of the gastric cavity andattached to a re-sectioned portion of the small intestine. However,because this complex procedure may require a great deal of operativetime, as well as extended and painful post-operative recovery, the RYGBprocedure is generally only utilized to treat people with morbidobesity.

In view of the highly invasive nature of the RYGB procedure, other lessinvasive bariatric procedures have been developed such as the Fobipouch, bilio-pancreatic diversion, gastroplasty (“stomach stapling”),vertical sleeve gastrectomy, and gastric banding. In addition,implantable devices are known which limit the passage of food throughthe stomach. Gastric banding procedures, for example, involve theplacement of a small band around the stomach near the junction of thestomach and the esophagus to restrict the passage from one part of thedigestive tract to another, thereby affecting a patient's feeling ofsatiety.

While the above-described bariatric procedures may be used for thetreatment of morbid obesity, in some cases the risks of these proceduresmay outweigh the potential benefits for the growing segment of thepopulation that is considered overweight. The additional weight carriedaround by these persons may still result in significant healthcomplications, but does not necessarily justify more invasive treatmentoptions. However, because conservative treatment with diet and exercisealone may be ineffective for reducing excess body weight in some cases,there is a need for treatment options that are less invasive and lowercost than the procedures discussed above.

It is known to create cavity wall plications through both laparoscopicand endoscopic procedures. Laparoscopic plication techniques can becomplicated and complex, however, as one or more surgical entry portsmay need to be employed to gain access to the surgical site.Furthermore, laparoscopically approaching the stomach may requireseparating the surrounding omentum prior to plication formation. Inendoscopic procedures, plication depth may suffer due to the sizerestrictions of the endoscopic lumen. For example, the rigid length anddiameter of a surgical device are limited based on what sizes can bereliably and safely passed trans-orally into the stomach. Furthermore,access and visibility within the gastric and peritoneal cavities may beprogressively limited in an endoscopic procedure as the extent of thereduction increases, because the volume of the gastric cavity isreduced.

In addition, existing devices for forming endoluminal plications mayutilize opposing jaws and a grasper element to draw tissue between thejaws. These devices may approach the cavity wall such that alongitudinal axis of the device is perpendicular to the cavity wall. Thegrasper element can then be advanced from the center of the open jaws,and used to draw tissue between the jaws to create the fold. However,the geometry of these devices limits the size of the plication that canbe formed to approximately the length of the jaws, as the grasper may beable to only draw the cavity wall tissue to the center of the jaws andno further. Moreover, in order to secure a plication with a plurality offasteners, these devices may need to release the tissue and berepositioned anew to apply each fastener. A merely exemplary plicationdevice is disclosed in U.S. Pat. Pub. No. 2013/0153642, entitled“Devices and Methods for Endoluminal Plication,” published Jun. 20,2013, now U.S. Pat. No. 9,119,615, issued Sep. 1, 2015, the disclosurewhich is incorporated by reference herein.

While various kinds of bariatric surgical instruments and associatedcomponents have been made and used, it is believed that no one prior tothe inventor(s) has made or used the invention described in the appendedclaims.

BRIEF DESCRIPTION OF THE DRAWINGS

While the specification concludes with claims which particularly pointout and distinctly claim this technology, it is believed this technologywill be better understood from the following description of certainexamples taken in conjunction with the accompanying drawings, in whichlike reference numerals identify the same elements and in which:

FIG. 1 depicts a perspective view of an exemplary surgical staplinginstrument;

FIG. 2 depicts a perspective view of a handle assembly of the instrumentof FIG. 1;

FIG. 3 depicts a perspective view of a shaft assembly of the instrumentof FIG. 1;

FIG. 4 depicts a perspective view of an articulation section of theinstrument of FIG. 1;

FIG. 5 depicts a perspective view of the shaft assembly, thearticulation section, and the end effector of the instrument of FIG. 1;

FIG. 6 depicts a perspective view of an exemplary end effector of theinstrument of FIG. 1;

FIG. 7 depicts a side elevational view of the end effector of FIG. 6;

FIG. 8 depicts an exploded perspective view of the end effector of FIG.6;

FIG. 9 depicts a perspective view of an anvil of the end effector ofFIG. 6;

FIG. 10 depicts a side elevational view of the anvil of FIG. 9;

FIG. 11 depicts a perspective view of an exemplary wheel assembly of theend effector of FIG. 6;

FIG. 12 depicts a cross-sectional view of the wheel assembly of FIG. 11,taken along line 12-12 of FIG. 11;

FIG. 13A depicts a top view of the wheel assembly of FIG. 11 and theanvil of FIG. 9 in a first position;

FIG. 13B depicts a top view of the wheel assembly of FIG. 11 and theanvil of FIG. 9 in a second position;

FIG. 13C depicts a top view of the wheel assembly of FIG. 11 and theanvil of FIG. 9 in a third position;

FIG. 13D depicts a top view of the wheel assembly of FIG. 11 and theanvil of FIG. 9 returned to the second position;

FIG. 13E depicts a top view of the wheel assembly of FIG. 11 and theanvil of FIG. 9 returned to the first position;

FIG. 14A depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the third position and with a vacuum port ina first position;

FIG. 14B depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the second position and with the vacuum portin the first position;

FIG. 14C depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the first position and with the vacuum portin the first position;

FIG. 14D depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the first position and with the vacuum portin a second position;

FIG. 15 depicts a side elevational view of a staple deck of the endeffector of FIG. 6;

FIG. 16 depicts a perspective view of a stapling assembly of the endeffector of FIG. 6;

FIG. 17 depicts an exploded perspective view of the stapling assembly ofFIG. 16;

FIG. 18A depicts a perspective view of the stapling assembly of FIG. 16with a wheel assembly, a driver, and a staple in a first position;

FIG. 18B depicts a perspective view of the stapling assembly of FIG. 16with the wheel assembly, the driver, and the staple in a secondposition;

FIG. 18C depicts a perspective view of the stapling assembly of FIG. 16with the wheel assembly, the driver, and the staple in a third position;

FIG. 18D depicts a perspective view of the stapling assembly of FIG. 16with the wheel assembly and the driver returned to the second position;

FIG. 18E depicts a perspective view of the stapling assembly of FIG. 16with the wheel assembly and the driver returned to the first positionand with another staple moved into the first position;

FIG. 19A depicts a cross-sectional view of the stapling assembly of FIG.16 with the wheel assembly, the driver, and the staple in the firstposition;

FIG. 19B depicts a cross-sectional view of the stapling assembly of FIG.16 with the wheel assembly, the driver, and the staple in the secondposition;

FIG. 19C depicts a cross-sectional view of the stapling assembly of FIG.16 with the wheel assembly, the driver, and the staple in the thirdposition;

FIG. 19D depicts a cross-sectional view of the stapling assembly of FIG.16 with the wheel assembly and the driver returned to the secondposition;

FIG. 19E depicts a cross-sectional view of the stapling assembly of FIG.16 with the wheel assembly and the driver returned to the first positionand with the other staple moved into the first position;

FIG. 20A depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the first position and with the vacuum portin the second position, adjacent to tissue;

FIG. 20B depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the first position and with the vacuum portin a third position, pulling tissue between the anvil and the stapledeck of the end effector;

FIG. 20C depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 returned to the second position, beginning tocompress the tissue between the anvil and the staple deck, and with thevacuum port in the third position;

FIG. 20D depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 returned to the third position, fullycompressing the tissue between the anvil and the staple deck, and withthe vacuum port in the third position;

FIG. 20E depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 in the third position, with the vacuum port inthe third position, and with a plurality of staples being driven throughthe compressed tissue;

FIG. 20F depicts a front elevational view of the end effector of FIG. 6with the anvil of FIG. 9 returned to the first position to release thestapled tissue, with the vacuum port in the third position furtherreleasing the stapled tissue, and with the plurality of staples of FIG.20E driven completely through the tissue;

FIG. 21A depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 in the first position and with the wheel assemblies of the endeffector of FIG. 6 in the first position;

FIG. 21B depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 in the first position, with the wheel assemblies of the endeffector of FIG. 6 in the first position, and with tissue drawn betweenthe anvil and the staple deck;

FIG. 21C depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 in the second position, beginning to compress the tissuebetween the anvil and the staple deck, and with the wheel assemblies ofthe end effector of FIG. 6 in the second position;

FIG. 21D depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 in the third position, fully compressing the tissue betweenthe anvil and the staple deck, and with the wheel assemblies of the endeffector of FIG. 6 in the third position;

FIG. 21E depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 in the third position, with the wheel assemblies of the endeffector of FIG. 6 in the third position, and with a plurality ofstaples being driven through the compressed tissue;

FIG. 21F depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 returned to the second position to begin releasing the stapledtissue, with the wheel assemblies of the end effector of FIG. 6 returnedto the second position, and with the plurality of staples of FIG. 21Edriven completely through the tissue; and

FIG. 21G depicts a top view of the end effector of FIG. 6 with the anvilof FIG. 9 returned to the first position to fully release the stapledtissue, with the wheel assemblies of the end effector of FIG. 6 returnedto the first position to index the next set of staples, and with theplurality of staples of FIG. 20E driven completely through the tissue;

FIG. 22 depicts a perspective view of tissue stapled by the end effectorof FIG. 6;

FIG. 23 is a front perspective view of a tissue acquisition memberincluding a secondary tissue acquirer that includes one or moregraspers; and

The drawings are not intended to be limiting in any way, and it iscontemplated that various embodiments of the technology may be carriedout in a variety of other ways, including those not necessarily depictedin the drawings. The accompanying drawings incorporated in and forming apart of the specification illustrate several aspects of the presenttechnology, and together with the description serve to explain theprinciples of the technology; it being understood, however, that thistechnology is not limited to the precise arrangements shown.

DETAILED DESCRIPTION

The following description of certain examples of the technology shouldnot be used to limit its scope. Other examples, features, aspects,embodiments, and advantages of the technology will become apparent tothose skilled in the art from the following description, which is by wayof illustration, one of the best modes contemplated for carrying out thetechnology. As will be realized, the technology described herein iscapable of other different and obvious aspects, all without departingfrom the technology. Accordingly, the drawings and descriptions shouldbe regarded as illustrative in nature and not restrictive.

I. Overview of Exemplary Endoluminal Stapler

FIGS. 1-5 depict an exemplary endoluminal stapling instrument (10)having a handle assembly (20), a shaft assembly (30), and an endeffector (100); each of which will be described in more detail below.Shaft assembly (30) extends distally from handle assembly (20) and endeffector (100) is coupled to a distal end of shaft assembly (30). Shaftassembly (30) and end effector (100) are dimensioned to enable shaftassembly (30) and end effector (100) to be inserted transorally througha patient's esophagus, to selectively position end effector (100) in thepatient's stomach in a minimally invasive manner. In brief, handleassembly (20) is operable to actuate an anvil (150), a vacuum head(130), and a plurality of stapling assemblies (200) to suction and grasptissue in the stomach, and to substantially simultaneously drive aplurality of staples (172) through the folded tissue. Staples (172) arebent to form completed staples by anvil (150), which is slidablyattached to end effector (100). Accordingly, tissue (2) may be stapledutilizing instrument (10) as shown in FIGS. 20A-22.

A. Exemplary Handle Assembly and Shaft Assembly

As shown in FIGS. 1-2, handle assembly (20) of the present exampleincludes a pistol grip (22), a pivoting trigger (24), a palm trigger(25), and an articulation control knob (26). While handle assembly (20)of the present example includes manually actuated triggers (24, 25) andknob (26), it should be understood that handle assembly (20) may includevarious other kinds of user input features in addition to or in lieu ofmanually actuated triggers (24, 25) and knob (26). Similarly, it shouldbe understood that handle assembly (20) may include one or more motorsthat are operable to drive end effector (100) and/or other features ofinstrument (10). Various suitable ways in which instrument (10) may beat least partially motorized will be apparent to those of ordinary skillin the art in view of the teachings herein.

As shown in FIG. 3, a plurality of cables (32) are disposed within shaftassembly (30). A proximal end of each cable (32) is secured to trigger(24) and a distal end of each cable is engaged with a respective wheelassembly (210, 180) in end effector (100). Trigger (24) is pivotabletoward and away from pistol grip (22) to selectively translate cables(32) proximally within shaft assembly (30) to thereby rotate wheelassemblies (210, 180) and to thereby actuate end effector (100) as willbe described in greater detail below. Cables (32) may be resilientlybiased (32) distally. For instance, the distal ends of cables (32) maywrap about a portion of respective wheel assemblies (210, 180) and thenbe coupled with a spring disposed within shaft assembly (30). Inaddition or in the alternative, trigger (24) and/or wheel assemblies(210, 180) may be resiliently biased by torsion springs or otherresilient members, which may effectively bias cables (32).

A cable (36) is also disposed within shaft assembly (30). A proximal endof cable (36) is secured to palm trigger (25) and a distal end of cable(36) is engaged with vacuum head (130). Palm trigger (25) is pivotabletoward and away from pistol grip (22) to selectively translate cable(36) proximally within shaft assembly (30) to thereby move vacuum head(130) laterally from end effector (100) as will be described in greaterdetail below. Cable (36) may be resiliently biased such that cable (36)is biased distally. For instance, vacuum head (130) may be biased towardend effector such that cable (36) is biased distally. As another merelyillustrative example, palm trigger (25) may be resiliently biased by atorsion spring or other resilient member, effectively biasing cable(36). It should be understood that pistol grip (22), trigger (24), andpalm trigger (25) may be modified, substituted, supplemented, etc. inany suitable way, and that the descriptions of such components hereinare merely illustrative. By way of example only, pistol grip (22),trigger (24), and/or palm trigger (25) may be configured and operable inaccordance with at least some of the teachings of U.S. Pat. Pub. No.2013/0153642, now U.S. Pat. No. 9,119,615, issued Sep. 1, 2015, thedisclosure which is incorporated by reference herein. Other suitablemodifications, substitutes, and supplements for pistol grip (22),trigger (24), and palm trigger (25) will be apparent to those ofordinary skill in the art in view of the teachings herein.

As shown in FIGS. 1, 4, and 5 shaft assembly (30) of the present exampleis substantially flexible along its length and includes an outer sheath(34) and an articulation section (40). Articulation section (40) isoperable to selectively laterally deflect end effector (100) at variousangles relative to a longitudinal axis defined by outer sheath (34). Asshown in FIGS. 1 and 5, articulation section (40) is configured toenable up to 180° deflection of end effector (100), such that endeffector (100) has a retrograde orientation parallel to the longitudinalaxis of shaft assembly (30), with end effector being laterally offsetfrom the longitudinal axis of shaft assembly (30). Of course, thisdegree of articulation is merely optional. Articulation section (40) mayinstead be configured to enable articulation to any other suitabledegree.

In some versions, articulation section (40) and/or some other portion ofouter sheath (34) includes a flexible outer sheath (e.g., a heat shrinktube, etc.) disposed about its exterior. Articulation section (40) ofshaft assembly (30) may take a variety of forms. By way of example only,articulation section (40) may be configured in accordance with at leastsome of the teachings of U.S. Pub. No. 2012/0078247, entitled“Articulation Joint Features for Articulating Surgical Device,”published Mar. 29, 2012, now U.S. Pat. No. 9,402,682, issued Aug. 2,2016, the disclosure of which is incorporated by reference herein. Asanother merely illustrative example, articulation section (40) may beconfigured in accordance with at least some of the teachings of U.S.Pub. No. 2012/0078248, entitled “Articulation Joint Features forArticulating Surgical Device,” published Mar. 29, 2012, now U.S. Pat.No. 9,220,559, issued Dec. 29, 2015, the disclosure of which isincorporated by reference herein. As yet another merely illustrativeexample, articulation section (40) may be configured in accordance withat least some of the teachings of U.S. Pat. Pub. No. 2013/0153642, nowU.S. Pat. No. 9,119,615, issued Sep. 1, 2015, the disclosure of which isincorporated by reference herein. Various other suitable forms thatarticulation section (40) may take will be apparent to those of ordinaryskill in the art in view of the teachings herein. It should also beunderstood that some versions of instrument (10) may simply lackarticulation section (40).

In some versions, shaft assembly (30) is also rotatable about thelongitudinal axis defined by sheath (34), relative to handpiece (20),via a rotation knob or some other feature (not shown). Such rotation mayprovide rotation of end effector (100) and shaft assembly (30)unitarily. In some other versions, the rotation knob is operable torotate end effector (100) without rotating articulation section (40) orany portion of shaft assembly (30) that is proximal of articulationsection (40). As another merely illustrative example, staplinginstrument (10) may include one rotation control that providesrotatability of shaft assembly (30) and end effector (100) as a singleunit; and another rotation control that provides rotatability of endeffector (100) without rotating articulation section (40) or any portionof shaft (30) that is proximal of articulation section (40). Othersuitable rotation schemes will be apparent to those of ordinary skill inthe art in view of the teachings herein. Of course, rotatable featuresmay simply be omitted if desired.

Articulation control knob (26) of the present example is operable toselectively control articulation section (40) of shaft assembly (30), tothereby selectively laterally deflect end effector (100) at variousangles relative to the longitudinal axis defined by sheath (34). Whilearticulation control knob (26) is in the form of a rotary dial in thepresent example, it should be understood that articulation control knob(26) may take numerous other forms. By way of example only, articulationcontrol knob (26) and/or other components of handle assembly (20) may beconstructed and operable in accordance with at least some of theteachings of U.S. Pub. No. 2012/0078243, entitled “Control Features forArticulating Surgical Device,” published Mar. 29, 2012, issued as U.S.Pat. No. 9,877,720 on Jan. 30, 2018, the disclosure of which isincorporated by reference herein. As another merely illustrativeexample, articulation control knob (26) and/or other components ofhandle assembly (20) may be constructed and operable in accordance withat least some of the teachings of U.S. Pub. No. 2012/0078244, entitled“Control Features for Articulating Surgical Device,” published Mar. 29,2012, now abandoned, the disclosure of which is incorporated byreference herein. As still another merely illustrative example,articulation control knob (26) and/or other components of handleassembly (20) may be constructed and operable in accordance with atleast some of the teachings of U.S. Pub. No. 2013/0023868, entitled“Surgical Instrument with Contained Dual Helix Actuator Assembly”published Jan. 24, 2013, now U.S. Pat. No. 9,545,253, issued Jan. 17,2017, the disclosure of which is incorporated by reference herein. Asyet another merely illustrative example, articulation control knob (26)and/or other components of handle assembly (20) may be constructed andoperable in accordance with at least some of the teachings of U.S. Pat.Pub. No. 2013/0153642, now U.S. Pat. No. 9,119,615, issued Sep. 1, 2015,the disclosure of which is incorporated by reference herein. Still othersuitable forms that articulation control knob (26) may take will beapparent to those of ordinary skill in the art in view of the teachingsherein. It should also be understood that some versions of instrument(10) may simply lack an articulation control knob (26) or similarfeature.

B. Exemplary End Effector

FIGS. 6-21G depict end effector (100) of the present example in greaterdetail. As shown in FIG. 6, end effector (100) of the present example isattached to a distal end of articulation section (40). End effector(100) comprises a stapling head assembly (110), a tissue advancingmember, such as vacuum head (130), and an anvil (150). As best seen inFIG. 8, the interior of stapling head assembly (110) presents alongitudinal channel (118). As will be described in more detail below,wheel assemblies (180) of end effector (100) are disposed withinlongitudinal channel (118). Cover (112) is selectively attachable tostapling head assembly (110) such that cover (112) covers longitudinalchannel (118) and wheel assemblies (180) as shown in FIG. 7. Such covermay prevent wheel assemblies (180) of end effector (100) from snaggingon tissue as end effector (100) is inserted into a patient. Vacuum head(130) of the present example is operable to provide suction and therebydraw tissue (2) between anvil (150) and stapling head assembly (110).Wheel assemblies (210, 180) of the present example are operable tolaterally drive anvil (150) toward and away from stapling head assembly(110), and to further drive staples (172) through tissue (2) that iscompressed between anvil (150) and the deck (116) of stapling headassembly (110) as will be described in greater detail below.

1. Exemplary Anvil

FIGS. 9-10 depict anvil (150) in greater detail. An interior surface(154) of anvil (150) presents a plurality of staple forming pockets(158) that are configured to receive and form plurality of staples(172). As best seen in FIG. 10, staple forming pockets (158) areoriented obliquely relative to a longitudinal axis defined by staplinghead assembly (110). By way of example only, staple forming pockets(158) may be formed according to the teachings of U.S. patentapplication Ser. No. 13/780,379, entitled “Staple Forming Features forSurgical Stapling Instrument,” filed Feb. 28, 2013, published on Aug.28, 2014 as U.S. Pub. No. 2014/0239037, issued as U.S. Pat. No.10,092,292 on Oct. 9, 2018, the disclosure of which is incorporated byreference herein. Alternatively, staple forming pockets (158) may haveany other suitable configuration. An arm (152) projects laterally from aproximal end of interior surface (154) of anvil (150). As best seen inFIG. 15, a proximal end of stapling head assembly (110) presents a slot(114) that extends through deck (116) of stapling head assembly (110).Arm (152) is slidably disposed within slot (114) such that interiorsurface (154) of anvil (150) is operable to slide laterally toward andaway from deck (116) of stapling head assembly (110), while maintaininga parallel relationship between anvil (150) and deck (116).Alternatively, anvil (150) may be pivotably connected to deck (116),with arm (152) being slidably disposed within slot (114) and pivotablyconnected to anvil (150) such that sliding arm (152) laterally towardand away from deck (116) maintains a non-parallel relationship betweenanvil (150) and deck (116). As will be discussed in more detail below,arm (152) defines a longitudinal channel (156) that spans the width ofarm (152).

As best seen in FIGS. 11-12, an anvil wheel assembly (180) comprises awheel (182), an axle (186), and a pin (188). Wheel (182) defines anannular channel (184) in an exterior surface of wheel (182). A pair oftransverse retention channels (187) are in communication with annularchannel (184). Annular channel (184) is configured to receive a cable(32A) of the plurality of cables (32), with an end of cable (32A) beingsecured in one or both of retention channels (187). It should thereforebe understood that translation of cable (32A) will rotate wheel (182),based on the direction of translation of cable (32A). Axle (186) issecured within a central opening (183) of wheel (182) such that wheel(182) rotates about axle (186). Pin (188) is rotatably secured within anoffset opening (185) of wheel (182) such that as wheel (182) rotatesabout axle (186), pin (188) orbits about axle (186). Pin (188) and axle(186) are oriented parallel to each other in this example.

A proximal end of stapling head assembly (110) defines a cavity that isconfigured to receive wheel (182). This cavity is in communication withslot (114), which is best seen in FIGS. 6-7. As best seen in FIG. 8, theproximal end of stapling head assembly (110) further defines an opening(120) that is configured to receive axle (186). Wheel assembly (180) isdisposed within stapling head assembly (110) and slot (114) such thataxle (186) is rotatably disposed within opening (120) and such thatwheel assembly (180) rotates within stapling head assembly (110). Wheelassembly (180) is oriented such that pin (188) extends into longitudinalchannel (156) of arm (152). Pin (188) is sized such that the diameter ofpin (188) is slightly smaller than the width of longitudinal channel(156), such that pin (188) freely slides longitudinally withinlongitudinal channel (156) and such that there is very little gapbetween an exterior surface of pin (188) and interior surfaces oflongitudinal channel (156). As will now be discussed in more detail,rotation of wheel assembly (180) is configured to cause lateral movementof anvil (150) relative to stapling head assembly (110).

FIGS. 13A-13E depict the mechanical interaction of wheel assembly (180)and anvil (150). It should be understood that stapling head assembly(110) is omitted from FIGS. 13A-13E for the sake of clarity, though alongitudinal axis (LA1) shown in FIGS. 13A-13E represents where deck(116) of stapling head assembly (110) would be located. As shown in FIG.13A, with pin (188) of wheel assembly (180) in a first rotationalposition relative to axle (186), anvil (150) is in a first lateralposition relative to the deck (116) of stapling head assembly (110) asrepresented by longitudinal axis (LA1). This first lateral positionrepresents a position in which interior surface (154) of anvil (150) isfurthest from deck (116) of stapling head assembly (110). As will bediscussed in more detail below, it is in this position that tissue (2)may be gathered between interior surface (154) of anvil (150) and deck(116) of stapling head assembly (110). Also, in this first rotationalposition, pin (188) is in a first longitudinal position relative tolongitudinal channel (156) of arm (152). Finally, the first rotationalposition of wheel assembly (180) as shown in FIG. 13A correlates withtrigger (24) being in a first pivotal position, where trigger (24) ispivoted furthest away from pistol grip (22).

As trigger (24) is pivoted toward pistol grip (22), trigger (24) drivesthe plurality of cables (32) longitudinally proximally such that wheelassembly (180) is rotated clockwise approximately 90° to a secondrotational position as shown in FIG. 13B. As pin (188) of wheel assembly(180) is rotated clockwise into the second rotational position, anvil(150) is transitioned to a second lateral position relative to the deck(116) of stapling head assembly (110) as represented by longitudinalaxis (LA1), via contact between the exterior surface of pin (188) and afirst interior surface of longitudinal channel (156) of arm (152).Furthermore, as pin (188) of wheel assembly (180) rotates from the firstrotational position to the second rotational position, pin (188) slideslongitudinally within longitudinal channel (156) from the firstlongitudinal position to a second longitudinal position. It should beunderstood that, the second rotational position of wheel assembly (180)correlates with a second pivotal position of trigger (24), where trigger(24) is pivoted approximately midway between the first pivotal positionof trigger (24) and pistol grip (22).

As trigger (24) is pivoted further toward pistol grip (22), trigger (24)further drives the plurality of cables (32) longitudinally proximallysuch that wheel assembly (180) is further rotated clockwiseapproximately 90° to a third rotational position as shown in FIG. 13C.As pin (188) of wheel assembly (180) is rotated clockwise into the thirdrotational position, anvil (150) is transitioned to a third lateralposition relative to the deck (116) of stapling head assembly (110) asrepresented by longitudinal axis (LA1), via contact between the exteriorsurface of pin (188) and the first interior surface of longitudinalchannel (156) of arm (152). This third lateral position represents aposition in which interior surface (154) of anvil (150) is closest todeck (116) of stapling head assembly (110). As will be discussed in moredetail below, it is in this third lateral position that tissue (2) willbe compressed and stapled. Furthermore, as pin (188) of wheel assembly(180) rotates from the second rotational position to the thirdrotational position, pin (188) slides longitudinally within longitudinalchannel (156) from the second longitudinal position back to the firstlongitudinal position. It should be understood that the third rotationalposition of wheel assembly (180) correlates with a third pivotalposition of trigger (24), where trigger (24) is closest to pistol grip(22).

Once trigger (24) is released, the distal bias applied to cables (32)drives trigger (24) away from pistol grip (22), and cables (32) aredriven distally such that wheel assembly (180) is rotatedcounter-clockwise approximately 90° back to the second rotationalposition as shown in FIG. 13D. As pin (188) of wheel assembly (180) isrotated counter-clockwise back to the second rotational position, anvil(150) is transitioned back to the second lateral position relative tothe deck (116) of stapling head assembly (110) as represented bylongitudinal axis (LA1), via contact between the exterior surface of pin(188) and a second interior surface of longitudinal channel (156) of arm(152). Furthermore, as pin (188) of wheel assembly (180) rotates fromthe third rotational position back to the second rotational position,pin (188) slides longitudinally within longitudinal channel (156) fromthe first longitudinal position to the second longitudinal position.Again, the second rotational position of wheel assembly (180) correlateswith the second pivotal position of trigger (24), where trigger (24) isapproximately midway between the first pivotal position of trigger (24)and pistol grip (22).

As trigger (24) is further driven away from pistol grip (22) via cables(32), cables (32) are further driven longitudinally distally such thatwheel assembly (180) is further rotated counter-clockwise approximately90° back to the first rotational position as shown in FIG. 13E. As pin(188) of wheel assembly (180) is rotated counter-clockwise back to thefirst rotational position, anvil (150) is transitioned back to the firstlateral position relative to the deck (116) of stapling head assembly(110) as represented by longitudinal axis (LA1), via contact between theexterior surface of pin (188) and the second interior surface oflongitudinal channel (156) of arm (152). Again, this first lateralposition represents a position in which interior surface (154) of anvil(150) is furthest from deck (116) of stapling head assembly (110).Furthermore, as pin (188) of wheel assembly (180) rotates from thesecond rotational position back to the first rotational position, pin(188) is slid longitudinally within longitudinal channel (156) from thesecond longitudinal position back to the first longitudinal position.Again, the first rotational position of wheel assembly (180) correlateswith trigger (24) being in the first pivotal position, where trigger(24) is furthest from pistol grip (22).

It should be understood from the foregoing that movement of trigger (24)from the first pivotal position to the third pivotal position and backto the first pivotal position, will drive anvil (150) from the firstlateral position to the third lateral position and back to the firstlateral position. It should also be understood that anvil (150) mayalternatively be driven using a variety of other structures, features,and techniques. Various examples of such alternatives will be apparentto those of ordinary skill in the art in view of the teachings herein.

2. Exemplary Vacuum Head

FIGS. 14A-14D and FIGS. 20A-20E depict exemplary operation of vacuumhead (130). Vacuum head (130) defines an inner lumen (not shown) thatconnects to one or more vacuum openings (not shown) formed in a tissueengaging surface (134) of vacuum head (130). A vacuum lumen (132) passeslongitudinally through shaft assembly (30) and articulation section (40)and is in fluid communication with the inner lumen of vacuum head (130)such that a vacuum is communicated to the vacuum openings of tissueengaging surface (134) and such that the vacuum openings are operable toengage and draw tissue against tissue engaging surface (134) of vacuumhead (130). As will be discussed in more detail below, this vacuum isfurther operable to cause vacuum head (130) to draw tissue into a gapdefined between anvil (150) and deck (116) of stapling head assembly(110).

Vacuum head (130) of the present example is pivotally coupled withinterior surface (154) of anvil (150) via a plurality of hinge members(138A, 138B). Hinge members (138A, 138B) of the present example comprisea first hinge member (138A) and a second hinge member (138B). Firsthinge member (138A) is pivotally connected at one end to a distal end ofvacuum head (130); and pivotally connected at the other end to aproximal end of anvil (150). Second hinge member (138B) is pivotallyconnected at one end to a distal end of vacuum head (130); and pivotallyconnected at the other end to a proximal end of anvil (150). Hingemembers (138A, 138B) are coupled on opposite sides of vacuum head (130).Additionally, hinge members (138A, 138B) may be offset longitudinallyrelative to each other. The pivotal connection between hinge members(138A, 138B) and vacuum head (130) and anvil (150) can be accomplishedusing, for example, a plurality hinge pins (139). Hinge members (138A,138B) allow vacuum head (130) to be driven toward and away from staplinghead assembly (110) while maintaining tissue engaging surface (134) atan orientation that is substantially parallel to stapling head assembly(110). There may also be some associated proximal/distal longitudinalmotion because hinge members (138A, 138B) drive vacuum head (130) alongan arcuate path. In particular hinge members (138A, 138B) can allowvacuum head (130) to move from the position shown in FIG. 14C to theposition shown in FIG. 14D and further to the position shown in FIG. 20Bwithout changing the substantially parallel orientation of vacuum head(130).

As shown in the series depicted in FIGS. 14A-14C, as anvil (150) isdriven from the third lateral position to the first lateral position,vacuum head (130) is concurrently driven from the third lateral positionto the first lateral position because vacuum head (130) is coupled toanvil (150). As also best seen in FIGS. 14C-14D, vacuum head (130) issized such that vacuum head (130) fits within the gap defined byinterior surface (154) of anvil (150) and deck (116) of stapling headassembly (110) when anvil (150) is in the first lateral position. Asshown in FIG. 14D, with anvil (150) in the first lateral position,vacuum head (130) can be driven downwardly within the gap defined byinterior surface (154) of anvil (150) and deck (116) of stapling headassembly (110) from a first vertical position to a second verticalposition. Vacuum head (130) may be biased downwardly toward the secondposition, for example, by a plurality of linear and/or torsion springsassociated with hinge members (138A, 138B). As will be discussed in moredetail below, in the second vertical position, a vacuum source can beactivated and vacuum head (130) may thereby draw tissue (2) againsttissue engaging surface (134) of vacuum head (130). Palm trigger (25)may be pivoted toward pistol grip (22) to draw cable (36) proximally, tothereby raise vacuum head (130) and draw tissue (2) from the secondvertical position to a third vertical position through the gap betweeninterior surface (154) of anvil (150) and deck (116) of stapling headassembly (110), thereby creating a gastric fold as shown in FIG. 20B.Also, as will be discussed in more detail below, anvil (150) can then bedriven back to the first position and one or more staples (172) can befired to secure the plication.

3. Exemplary Stapling Assemblies

Stapling head assembly (110) of the present example comprises pluralityof stapling assemblies (200). While stapling head assembly (100)includes four stapling assemblies (200) in the present example, itshould be understood that any other suitable number of staplingassemblies (200) may be incorporated into stapling head assembly (110).As shown in FIGS. 16-19E, each stapling assembly (200) comprises a wheelassembly (210) and a staple cartridge (230). Wheel assembly (210)comprises a wheel (212), an axle (214), and a pin (216). Wheel (212)comprises a circular channel (218) defined in an exterior surface ofwheel (212). Circular channel (218) is configured to receive a cable ofthe plurality of cables (32). It should be understood that wheels (212)are engaged with respective cables (32) similar to the engagement ofwheel (182) with cable (32A). Translation of cables (32) is thusconfigured to rotate corresponding wheels (212). Axle (214) is securedwithin a central opening of wheel (212) such that wheel (212) rotatesabout axle (214). Pin (216) is rotatably secured within an offsetopening of wheel (212) such that as wheel (212) rotates about axle(214), pin (216) also orbits about axle (214). Pin (216) and axle (214)are oriented parallel to each other in this example.

As shown in FIG. 15, deck (116) of stapling head assembly (110) presentsa plurality of slots (115) that extend laterally through stapling headassembly (110). Slots (115) are oriented obliquely at angles similar tothe angles at which staple forming pockets (158) are obliquely oriented.It should be understood that each slot of the plurality of slots (115)laterally aligns with a corresponding staple forming pocket (158) ofanvil (150). As best seen in FIG. 8, stapling head assembly (110)presents a plurality of circular recesses (122) within longitudinalchannel (118) of stapling head assembly (110). Each circular recess(122) defines a respective top surface (121). Each top surface (121) isoriented at an oblique angle substantially similar to the oblique angleof staple forming pockets (158) and slots (115). A distal portion ofeach circular recess (122) is in communication with a respective slot(115) via an opening (123). Each circular recess (122) presents anopening (124) that extends from a respective top surface (121) of eachcircular recess (122) into stapling head assembly (110). Each axle (214)of the plurality of wheel assemblies (210) is rotatably disposed withina respective opening (124) such that each wheel assembly (210) rotateswithin a respective circular recess (122). Each wheel assembly (210) isoriented within a respective circular recess (122) such that pin (216)extends through a respective opening (123) and into slot (115) ofstapling head assembly (110).

Each staple cartridge (230) comprises a drive sled (232), plurality ofstaples (172), a plate (239), a wave spring (240), and a cartridge body(242). Slots (115) are each configured to selectively receive andtemporarily secure a single staple cartridge (230) in stapling headassembly (110). Drive sled (232) comprises a pair of projections (234A,234B) extending transversely from a base (236) of drive sled (232).Projections (234A, 234B) define a channel (238) between them. Base (236)of drive sled (232) presents a staple engagement surface (237) that isconfigured to engage and drive staples (172) as will be discussed inmore detail below. As best seen in FIGS. 19A-19E, staple engagementsurface (237) of the present example has a curved cross-sectionalprofile, with a radius selected to complement the radius of the crown ofeach staple (172). Of course, staple engagement surface (237) may haveany other suitable configuration.

Cartridge body (242) defines a pair of slots (244) within opposinginterior surfaces of at a top of cartridge body (242). Slots (244) areconfigured to slidably receive base (236) of drive sled (232) such thatdrive sled (232) freely slides within slots (244) of cartridge body(242). When staple cartridge (230) is assembled, staples (172) arepositioned below base (236) of drive sled (232) and above plate (239)within cartridge body (242). Wave spring (240) is disposed below plate(239) and, once staple cartridge (230) is inserted into a respectiveslot (115), wave spring (240) is configured to resiliently bear againsta bottom interior surface of cartridge body (242) and thus exert anupward biasing force upon a bottom surface of plate (239) and staples(172). Cartridge body (242) presents a pair of projections (243)extending inwardly. Projections (243) prevent wave spring (240) fromdriving drive sled (232) and staples (172) beyond a top surface ofcartridge body (242).

Each wheel assembly (210) is further oriented within a respectivecircular recess (122) such that within each slot (115), a respective pin(216) of each wheel assembly (210) extends into a respective channel(238) of each drive sled (232). Pin (216) is sized such that thediameter of pin (216) is slightly smaller than the width of channel(238) such that pin (216) slides longitudinally within channel (238)freely and such that there is very little gap between an exteriorsurface of pin (216) and interior surfaces of channel (238). As will bediscussed in more detail below, rotation of wheel assembly (210) isconfigured to cause movement of drive sled (232) relative to cartridgebody (242).

FIGS. 18A-18E and 19A-19E depict the mechanical interaction of wheelassembly (210) and staple cartridge (230). As shown in FIGS. 18A and19A, with pin (216) of wheel assembly (210) in a first rotationalposition relative to axle (214), drive sled (232) of stapled cartridge(230) is in a first lateral position. This first lateral positionrepresents a position in which staples (172) are not covered by base(236) of drive sled (232). With drive sled (232) in the first lateralposition, wave spring (240) drives staples (172) upwardly relative tocartridge body (242) such that a first staple (172A) of staples (172) ispositioned within slots (244), with projections (243) retaining staple(172A) in cartridge body (242). Also, in the first rotational position,pin (216) is in a first longitudinal position relative to channel (238)of drive sled (232). Finally, the first rotational position of wheelassembly (210) correlates with trigger (24) being in the first pivotalposition, where trigger (24) is furthest from pistol grip (22).

As trigger (24) is pivoted toward pistol grip (22), trigger (24) drivesthe plurality of cables (32) longitudinally proximally such that wheelassembly (210) is rotated counter-clockwise approximately 90° to asecond rotational position as shown in FIGS. 18B and 19B. As pin (216)of wheel assembly (210) is rotated counter-clockwise into the secondrotational position, drive sled (232) is transitioned to a secondlateral position via contact between the exterior surface of pin (216)and a first interior surface of channel (238) of drive sled (232). Asdrive sled (232) is transitioned to the second lateral position, stapleengagement surface (237) of base (236) engages first staple (172A) anddrives first staple (172A) laterally as well. Furthermore, as pin (216)of wheel assembly (210) rotates from the first rotational position tothe second rotational position, pin (216) slides longitudinally withinchannel (238) from the first longitudinal position to a secondlongitudinal position. It should be understood that the secondrotational position of wheel assembly (210) correlates with the secondpivotal position of trigger (24), where trigger (24) is approximatelymidway between the first pivotal position of trigger (24) and pistolgrip (22).

As trigger (24) is pivoted further toward pistol grip (22), trigger (24)further drives the plurality of cables (32) longitudinally proximallysuch that wheel assembly (210) is further rotated counter-clockwiseapproximately 90° to a third rotational position as shown in FIGS. 18Cand 19C. As pin (216) of wheel assembly (210) is rotatedcounter-clockwise into the third rotational position, drive sled (232)is transitioned to a third lateral position via contact between theexterior surface of pin (216) and the first interior surface of channel(238) of drive sled (232). As drive sled (232) is transitioned to thethird lateral position, drive sled (232) drives first staple (172A)further laterally as well. As will be discussed in more detail below, itis in this lateral position, that first staple (172A) is driven into andformed by a corresponding staple pocket (158) of anvil (150).Furthermore, as pin (216) of wheel assembly (210) rotates from thesecond rotational position to the third rotational position, pin (216)slides longitudinally within channel (238) from the second longitudinalposition back to the first longitudinal position. It should beunderstood that the third rotational position of wheel assembly (210)correlates with the third pivotal position of trigger (24), wheretrigger (24) is closest to pistol grip (22).

Once trigger (24) is released the distal bias applied to cables (32)drives trigger (24) away from pistol grip (22), and cables (32) aredriven longitudinally distally such that wheel assembly (210) is rotatedclockwise approximately 90° back to the second rotational position asshown in FIGS. 18D and 19D. As pin (216) of wheel assembly (210) isrotated clockwise back to the second rotational position, drive sled(232) is transitioned back to the second lateral position via contactbetween the exterior surface of pin (216) and a second interior surfaceof channel (238) of drive sled (232). Furthermore, as pin (216) of wheelassembly (210) rotates from the third rotational position back to thesecond rotational position, pin (216) slides longitudinally withinchannel (238) from the first longitudinal position to the secondlongitudinal position. Again, the second rotational position of wheelassembly (210) correlates with the second pivotal position of trigger(24), where trigger (24) is approximately midway between the firstpivotal position of trigger (24) and pistol grip (22).

As trigger (24) is further driven away from pistol grip (22) via cables(32), cables (32) are further driven longitudinally distally such thatwheel assembly (210) is further rotated clockwise approximately 90° backto the first rotational position as shown in FIGS. 18E and 19E. As pin(216) of wheel assembly (210) is rotated clockwise back to the firstrotational position, drive sled (232) is transitioned back to the firstlateral position via contact between the exterior surface of pin (216)and the second interior surface of channel (238) of drive sled (232).Again, this first lateral position represents a position in whichplurality of staples (172) is not covered by base (236) of drive sled(232). With drive sled (232) in the first lateral position, wave spring(240) drives plurality of staples (172) upwardly relative to cartridgebody (242) such that a second staple (172B) of the plurality of staples(172) is positioned within slots (244), with projections (243) retainingstaple (172B) in cartridge body (242). Furthermore, as pin (216) ofwheel assembly (210) rotates from the second rotational position back tothe first rotational position, pin (216) is slid longitudinally withinchannel (238) from the second longitudinal position back to the firstlongitudinal position. Again, the first rotational position of wheelassembly (210) correlates with trigger (24) being in the first pivotalposition, where trigger (24) is furthest from pistol grip (22).

It should be understood from the foregoing that movement of trigger (24)from the first pivotal position to the third pivotal position and backto the first pivotal position, will drive staples (172) (a single staple(172) from each stapling assembly (200)) laterally such that staples(172) are driven laterally through tissue (2) and into staple formingpockets (158) of anvil (150). It should also be understood that staples(172) may alternatively be driven using a variety of other structures,features, and techniques. By way of example only, while staplingassemblies (200) are all actuated simultaneously in the present example,it should be understood that stapling assemblies (200) may instead beactuated in a sequence. It should also be understood that each staplingassembly (200) may have its own associated cable (32) that runs alongthe length of shaft assembly (30). In some such versions, staplingassemblies (200) may be actuated independently from each other. In someother versions, a single cable extends along the length of shaftassembly (30) and is then split into separate cables (32), on a perstapling assembly (200) basis, at a coupling located at or near endeffector (100). As yet another merely illustrative example, the twodistal-most stapling assemblies (200) may be simultaneously driven by afirst shared cable (32) while the two proximal-most stapling assemblies(200) are simultaneously driven by a second shared cable (32). As stillanother merely illustrative example, wheel assemblies (210) may bejoined by rigid links (like wheels on a locomotive train), with theproximal-most wheel (212) being the only one directly coupled with acable (32). It should also be understood that one or more lockoutfeatures may be incorporated to prevent stapling assemblies (200) frombeing actuated before anvil (150) reaches a closed position. Variousother suitable alternatives will be apparent to those of ordinary skillin the art in view of the teachings herein.

4. Exemplary Full Sequence of Operation of End Effector

FIGS. 20A-22 depict exemplary stages in a full sequence of operation ofend effector (100). It should be understood that cover (112) and vacuumhead (130) are omitted from FIGS. 21A-21G for the sake of clarity. Thestages shown in FIGS. 20A-22 occur after end effector (100) has beeninserted transorally through a patient's esophagus and into thepatient's stomach. Articulation section (40) has been actuated toposition end effector (100) at an orientation suitable for forming aplication in the tissue (2) of the patient's stomach. For instance,articulation section (40) may be manipulated such that engaging surface(134) of vacuum head (130) is substantially parallel to the mucosaltissue (2) of the patient's stomach. In some instances, end effector(100) may be positioned adjacent to the anterior region of mucosaltissue (2) of the patient's stomach. In some other instances, endeffector (100) may be positioned adjacent to the posterior region ofmucosal tissue (2) of the patient's stomach. Alternatively, end effector(100) may be positioned adjacent to the region of mucosal tissue (2)associated with the greater curvature or the lesser curvature of thepatient's stomach, in the vicinity of the fundus of the patient'sstomach or in the vicinity of the antrum of the stomach.

As shown in FIG. 21A, with anvil (150) in the first lateral position,wheel assemblies (210) are in the first rotational position. In thefirst lateral position, tissue (2) is gathered between interior surface(154) of anvil (150) and deck (116) of stapling head assembly (110) byvacuum head (130) as shown in FIGS. 20A and 21B. In particular, withvacuum head (130) in the second vertical position, a vacuum source isactivated and vacuum head (130) draws tissue (2) against tissue engagingsurface (134) of vacuum head (130). As palm trigger (25) is pivotedtoward pistol grip (22), cable (36) is drawn proximally to thereby raisevacuum head (130) and drawn tissue (2) from the second position to thethird position through the gap between interior surface (154) of anvil(150) and deck (116) of stapling head assembly (110) thereby creating agastric plication as shown in FIG. 20B.

Tissue (2) is then compressed between interior surface (154) of anvil(150) and deck (116) of stapling head assembly (110) by pivoting trigger(24) toward pistol grip (22) as shown in FIG. 20C-20D and FIGS. 21C-21D.In particular, as trigger (24) is pivoted toward pistol grip (22), anvil(150) is driven laterally from the first lateral position shown in FIGS.20A-20B and 21A-21B, to the second lateral position shown in FIGS. 20Cand 21C, and finally to the third lateral position shown in FIGS. 20Dand 21D, to thereby compress tissue (20) between interior surface (154)of anvil (150) and deck (116) of stapling head assembly (110). Duringthis transition, wheel assemblies (210) are rotated from the firstrotational position, to the second rotational position, and then to thethird rotational position such that at the point where tissue (2) iscompletely compressed between interior surface (154) of anvil (150) anddeck (116) of stapling head assembly (110).

Once tissue (2) is completely compressed between interior surface (154)of anvil (150) and deck (116) of stapling head assembly (110), drivesleds (232) of stapling assemblies (200) are actuated to thereby drivestaples (172) (a single staple (172) from each stapling assembly (200))through tissue (2) as shown in FIGS. 20E and 21E, and into stapleforming pockets (158) of anvil (150). It should be understood thatcables (32) and/or other features of instrument (10) may be configuredto provide full closure of anvil (150) at the position shown in FIGS.20D and 21D before staples (172) are driven into tissue (2), with anvil(150) movement ceasing while staples (172) are being driven into tissue(2). By way of example only, a clutch mechanism may automaticallytransfer motion of trigger (24) from anvil (150) to stapling assemblies(200) upon full closure of anvil (150) at the position shown in FIGS.20D and 21D. As another merely illustrative example, separate triggersmay be provided to actuate anvil (150) and stapling assemblies (200).Various suitable ways in which the actuation of anvil (150) and staplingassemblies (200) may be appropriately sequenced will be apparent tothose of ordinary skill in the art in view of the teachings herein.

After the plurality of staples have been driven through tissue (2) andformed by staple forming pockets (158), trigger (24) is released tothereby drive anvil (150) from the third lateral position to the firstlateral position, and vacuum head (130) releases the tissue by stoppingsuction, leaving behind a stapled plication (4) as shown in FIGS.21F-21G and 22. In some instances, suction is stopped at vacuum head(130) once tissue (2) is sufficiently compressed between anvil (150) anddeck (116) of stapling head assembly (110). In some other instances,suction is not stopped at vacuum head (130) until staples (172) arefully deployed in tissue (2) and formed by anvil (150).

Plication (4) reduces the capacity of the stomach in this example. Itshould be understood that the plication (4) may include all layers ofstomach tissue, such that plication (4) provides apposed regions ofserosa on the exterior of the patient's stomach. It should be furtherunderstood that, over time, such apposition of serosa may ultimatelyresult in serosa-to-serosa bonding. In some such instances, theserosa-to-serosa bond may maintain the plication even if staples (172)eventually biodegrade or are absorbed.

In some instances, it may be desirable to apply several series ofstaples (172) to tissue (2). For instance, it may be desirable to applyseveral series of staples (172) to a single plication (4) of tissue (2),such as to further secure the plication (4) or to increase the size ofthe plication (4). A second row of staples (172) may be applied in linewith the first row of staples (172), offset from the first row ofstaples (172), or otherwise. As another merely illustrative example, itmay be desirable to create several plications (4) within the stomach,such as one or more plications (4) at the anterior side of the stomachin combination with one or more plications (4) at the posterior side ofthe stomach. As noted above, each stapling assembly (200) is preloadedwith four staples (172). It should therefore be understood that endeffector (100) may be actuated four times to apply four series ofstaples (172). Of course, any other suitable number of staples (172) maybe preloaded into each stapling assembly (200).

There are numerous other ways in which more than series of staples (172)may be applied to tissue (2) within a single procedure. By way ofexample only, several instruments (10) may be used, each instrument (10)being actuated to create a corresponding single plication (4) (or fourcorresponding sets of staple rows). As another merely illustrativeexample, end effector (100) may be configured to enable replacement ofstaple cartridges (230). Alternatively, end effector (100) may enablereplacement of stapling head assembly (110). Alternatively, instrument(10) may enable replacement of end effector (100). Various suitable waysin which instrument (10) may provide replaceability of one or morecomponents will be apparent to those of ordinary skill in the art inview of the teachings herein. Similarly, various other suitable ways inwhich instrument (10) may be used will be apparent to those of ordinaryskill in the art in view of the teachings herein.

Secondary Tissue Acquirer

In some embodiments, the tissue acquisition member alone may not besufficiently strong (e.g., may not have sufficient vacuum strength) tomaintain its hold on tissue drawn against the tissue engaging surface asthe tissue acquisition member is raised away from the first and secondjaws. As a result, a tissue engaging element in the form of a secondarytissue acquirer can he employed to help retain the position of tissuedrawn against the tissue acquisition member. A person skilled in the artwill appreciate that any secondary tissue acquisition member can beusing with any primary tissue acquisition member disclosed herein, oralternatively the secondary tissue acquisition member can be usedinstead of the primary tissue acquisition members disclosed herein.

The secondary tissue acquirer can have a variety of configurations.Generally, the secondary tissue acquirer is coupled to the tissueacquisition member and configured to engage and retain tissue in aparticular position relative to the tissue acquisition member. Thesecondary tissue acquirer can include any of one or more hooks,graspers, and clamps pivotally or otherwise connected to the tissueacquisition member.

In one exemplary embodiment illustrated in FIG. 23, a tissue acquisitionmember (2500) includes a tissue engaging element in the form of asecondary tissue acquirer (2502) connected to its distal end. Thesecondary tissue acquirer (2502) includes opposing graspers (2504, 2506)that are pivotally connected to a pin (2508) that extends from thedistal end of the tissue acquisition member (2500). The proximal end ofthe grasper (2504) is pivotally connected to a linkage (2510), and theproximal end of the grasper (2506) is pivotally connected to a linkage(2512). The linkages (2510, 2512) are, in turn, connected to each otherpivotally at point P.

To operate the secondary tissue acquirer (2502), an actuating cable canbe attached to point P to pull it upward, thereby causing the graspers(2504, 2506) to pivot around the pin (2508) toward each other. This issimilar to the operation of an ice block pick. When the graspers (2504,2506) pivot toward each other, they can engage any tissue disposedtherebetween. Further, the graspers (2504, 2506) can he formed witheither sharp or dull distal ends to aid in tissue engagement.

An actuating cable connected to the secondary tissue acquirer (2502) canbe routed, for example, over the top of the tissue acquisition member(2500). In some embodiments, the tissue acquisition member (2500) mayhave a track, depression, or other guide formed on its upper surface toaccommodate the actuating cable extending to the secondary tissueacquirer (2502) on the distal end of the tissue acquisition member(2500).

II. Miscellaneous

It should also be understood that any one or more of the teachings,expressions, embodiments, examples, etc. described herein may becombined with any one or more of the other teachings, expressions,embodiments, examples, etc. that are described herein. Theabove-described teachings, expressions, embodiments, examples, etc.should therefore not be viewed in isolation relative to each other.Various suitable ways in which the teachings herein may be combined willbe readily apparent to those of ordinary skill in the art in view of theteachings herein. Such modifications and variations are intended to beincluded within the scope of the claims.

It should be appreciated that any patent, publication, or otherdisclosure material, in whole or in part, that is said to beincorporated by reference herein is incorporated herein only to theextent that the incorporated material does not conflict with existingdefinitions, statements, or other disclosure material set forth in thisdisclosure. As such, and to the extent necessary, the disclosure asexplicitly set forth herein supersedes any conflicting materialincorporated herein by reference. Any material, or portion thereof, thatis said to be incorporated by reference herein, but which conflicts withexisting definitions, statements, or other disclosure material set forthherein will only be incorporated to the extent that no conflict arisesbetween that incorporated material and the existing disclosure material.

Versions of the devices described above may have application inconventional medical treatments and procedures conducted by a medicalprofessional, as well as application in robotic-assisted medicaltreatments and procedures. By way of example only, various teachingsherein may be readily incorporated into a robotic surgical system suchas the DAVINCI™ system by Intuitive Surgical, Inc., of Sunnyvale, Calif.

Versions described above may be designed to be disposed of after asingle use, or they can be designed to be used multiple times. Versionsmay, in either or both cases, be reconditioned for reuse after at leastone use. Reconditioning may include any combination of the steps ofdisassembly of the device, followed by cleaning or replacement ofparticular pieces, and subsequent reassembly. In particular, someversions of the device may be disassembled, and any number of theparticular pieces or parts of the device may be selectively replaced orremoved in any combination. Upon cleaning and/or replacement ofparticular parts, some versions of the device may be reassembled forsubsequent use either at a reconditioning facility, or by a userimmediately prior to a procedure. Those skilled in the art willappreciate that reconditioning of a device may utilize a variety oftechniques for disassembly, cleaning/replacement, and reassembly. Use ofsuch techniques, and the resulting reconditioned device, are all withinthe scope of the present application.

By way of example only, versions described herein may be sterilizedbefore and/or after a procedure. In one sterilization technique, thedevice is placed in a closed and sealed container, such as a plastic orTYVEK bag. The container and device may then be placed in a field ofradiation that can penetrate the container, such as gamma radiation,x-rays, or high-energy electrons. The radiation may kill bacteria on thedevice and in the container. The sterilized device may then be stored inthe sterile container for later use. A device may also be sterilizedusing any other technique known in the art, including but not limited tobeta or gamma radiation, ethylene oxide, or steam.

Having shown and described various embodiments of the present invention,further adaptations of the methods and systems described herein may beaccomplished by appropriate modifications by one of ordinary skill inthe art without departing from the scope of the present invention.Several of such potential modifications have been mentioned, and otherswill be apparent to those skilled in the art. For instance, theexamples, embodiments, geometrics, materials, dimensions, ratios, steps,and the like discussed above are illustrative and are not required.Accordingly, the scope of the present invention should be considered interms of the following claims and is understood not to be limited to thedetails of structure and operation shown and described in thespecification and drawings.

We claim:
 1. A surgical instrument comprising: (a) a body; (b) a motor;(c) a shaft assembly extending distally from the body, wherein the shaftassembly comprises a proximal end and a distal end; and (d) an endeffector coupled with the distal end of the shaft assembly, wherein theend effector comprises: (i) a first jaw, (ii) a second jaw opposed fromthe first jaw, wherein the first and second jaws are operable totransition between an open state for receiving tissue therebetween and aclosed state for clamping tissue therebetween, wherein the first andsecond jaws are configured to apply a plurality of staples to theclamped tissue while remaining in the closed state, (iii) a tissueadvancing member operable to engage and draw tissue between the firstand second jaws in the open state, and (iv) a drive assembly operativelycoupled with the motor, wherein the drive assembly includes a rotarymember at least partially housed within the end effector and operativelycoupled with at least one jaw of the first and second jaws, wherein themotor is operable to drive rotation of the rotary member to therebyactuate the at least one jaw and transition the first and second jawsbetween the open state and the closed state in response to rotation ofthe rotary member.
 2. The surgical instrument of claim 1, wherein thetissue advancing member includes a tissue engaging surface, wherein thetissue advancing member is operable to provide a non-atmospheric airpressure at the tissue engaging surface for engaging and moving tissue.3. The surgical instrument of claim 2, wherein the tissue advancingmember is operable to provide a vacuum at the tissue engaging surfacefor engaging and drawing tissue against the tissue engaging surface. 4.The surgical instrument of claim 2, wherein the end effector furtherincludes at least one outwardly projecting tissue engaging elementcoupled to the tissue advancing member and configured to engage tissueindependently of the non-atmospheric air pressure provided by the tissueadvancing member.
 5. The surgical instrument of claim 4, wherein the atleast one outwardly projecting tissue engaging element is movablebetween a first position for engaging tissue and a second position fordisengaging tissue.
 6. The surgical instrument of claim 1, wherein thefirst and second jaws extend longitudinally, wherein the tissueadvancing member is configured to move tissue laterally relative to atleast one of the first or second jaws.
 7. The surgical instrument ofclaim 1, wherein the first and second jaws extend longitudinally,wherein the tissue advancing member is configured to move tissuelongitudinally relative to at least one of the first or second jaws. 8.The surgical instrument of claim 1, further comprising an articulationsection configured to articulate the end effector relative to alongitudinal axis of the shaft assembly.
 9. The surgical instrument ofclaim 1, wherein the first jaw includes a stapling head assemblyactuatable to eject staples, and the second jaw includes an anvilconfigured to form staples ejected by the stapling head assembly,wherein the first and second jaws are configured to apply at least onerow of staples to tissue positioned between the first and second jawsupon each actuation of the stapling head assembly, wherein the staplinghead assembly is configured to house a quantity of staples sufficient toenable application of a plurality of rows of staples to the tissue. 10.The surgical instrument of claim 1, wherein the second jaw is movablelinearly relative to the first jaw.
 11. The surgical instrument of claim1, wherein the end effector is configured to maintain a parallelrelationship between the first jaw and the second jaw as the first andsecond jaws transition between the open state and the closed state. 12.The surgical instrument of claim 1, wherein the rotary member of thedrive assembly comprises a wheel assembly.
 13. The surgical instrumentof claim 1, wherein the rotary member of the drive assembly is rotatableabout its axis to move the second jaw relative to the first jaw andthereby transition the first and second jaws from the open state to theclosed state.
 14. The surgical instrument of claim 1, wherein the rotarymember of the drive assembly comprises a first rotary member rotatableabout a first axis, wherein the drive assembly of the end effectorfurther includes second and third rotary members, wherein the secondrotary member is rotatable about a second axis to drive a first stapleinto tissue positioned between the first and second jaws, wherein thethird rotary member is rotatable about a third axis to drive a secondstaple into tissue positioned between the first and second jaws.
 15. Asurgical instrument comprising: (a) a body; (b) a motor; (c) a shaftassembly extending distally from the body, wherein the shaft assemblycomprises a proximal end and a distal end; and (d) an end effectorcoupled with the distal end of the shaft assembly, wherein the endeffector comprises: (i) a stapling head assembly configured to eject aplurality of staples, (ii) an anvil having a plurality of staple formingpockets configured to form the staples ejected by the stapling headassembly, wherein the anvil is movable relative to the stapling headassembly between an open state for receiving tissue therebetween and aclosed state for clamping tissue therebetween, (iii) a tissue advancingmember operable to engage and draw tissue between the stapling headassembly and the anvil in the open state, and (iv) a drive assemblyoperatively coupled with the motor and including first and second drivenmembers offset from one another along a longitudinal axis of the endeffector, wherein the motor is operable to drive movement of the firstdriven member to move the anvil relative to the stapling head assemblybetween the open state and the closed state; wherein the motor isfurther operable to drive movement of the second driven member to ejecta staple from the stapling head assembly.
 16. The surgical instrument ofclaim 15, wherein the first driven member is configured to rotate abouta first axis and the second driven member is configured to rotate abouta second axis.
 17. A surgical instrument comprising: (a) a body; (b) amotor; (c) a shaft assembly extending distally from the body, whereinthe shaft assembly comprises a proximal end and a distal end; and (d) anend effector coupled with the distal end of the shaft assembly, whereinthe end effector comprises: (i) a first jaw supporting a stapling headassembly configured to eject a plurality of staples, (ii) a second jawopposed from the first jaw, wherein the second jaw supports an anvilhaving a plurality of staple forming pockets configured to form thestaples ejected by the stapling head assembly, wherein the first andsecond jaws are operable to transition between an open state forreceiving tissue therebetween and a closed state for clamping andstapling tissue therebetween, (iii) a tissue advancing member coupled tothe second jaw, wherein the tissue advancing member is operable toengage and draw tissue between the stapling head assembly and the anvilwhen the first and second jaws are in the open state, and (iv) a wheeloperatively coupled with the motor and the second jaw, wherein the motoris operable to drive rotation of the wheel at the end effector tothereby actuate the second jaw and the tissue advancing member relativeto the first jaw.
 18. The surgical instrument of claim 1, wherein theend effector extends along a longitudinal axis, wherein the first andsecond jaws are configured to remain parallel to the longitudinal axisas they transition between the open state and the closed state.
 19. Thesurgical instrument of claim 17, wherein anvil is configured to remainparallel to the deck as the first and second jaws move between the openstate and the closed state.
 20. The surgical instrument of claim 17,wherein the wheel is at least partially housed within the end effector.